Socio demographic profile of study participants
Fig. 2, shows the socio demographic characteristics of the 159 respondents. There were 54.5% males and 45.5% females aged 15-65 years old with the majority (43.1%) aged between 26 and 35 years old.
Respondents held nine distinct job titles (Fig.2 with a majority being nurses (80%) followed by general medical practitioners (6.3%). Education levels included secondary (14.9%), diploma (57.8%), bachelors (24%), and masters (3.2%).
Availability of SRH services
Availability of services related to HIV and STDs themes at the surveyed health facilities are presented in Table 2. STDs testing was available in 92.3% of facilities, but only 64.8% of health facilities surveyed give treatment. HIV testing was available in 86.2% of facilities, but self-testing and self-testing kits were available in only 25% and 19.7% of the facilities, respectively. Only 42% of facilities give HIV treatment on the same day of diagnosis and only 31.6% facilities give treatment at any time. More than 80% of facilities offer HIV-counseling and 64.2% practice adult male circumcision. On the family planning related services, 85.5% of facilities may offer contraceptive methods, including combined oral pills (78.3%), progesterone pills (75.5%), male condoms (73.6%), female emergency contraceptives (63.9%), Depo-Provera injection (66%), hormonal implant (53.6%), intrauterine device (IUD) (49%), female condom (21%), lubricants (14.1%), vasectomy (11.5%), and tubal ligation (21.8%). Fertility awareness, antenatal counseling, and postnatal care may be available in 45-52% of facilities.
SRH services that adolescents could use, were mentioned to be available but often under-utilized and expire before being utilised, leading to wastage of scarce health resources.
“The male’s condoms are available, but there is stock-out of the female’s condoms. The previous females’ condoms expired because the clients did not request them. The females say that they do not use female condoms because of the difficulty with the insertion of the condom during sex. The participants also do not like using them because of the difficulties in using them during sexual intercourse” — nurse _in Gasabo District.
We also aimed to document the package of SRH services available at health facilities, and the respondents expressed that some services are not available at their facilities, due to the predetermined SRH health care package for health facilities that are set by the Ministry of Health guidelines. The respondents feel that if they were allowed to provide some services in their health facilities, they would have had all the SRH services needed by the adolescents.
“This private institution provides the tests and treatments of STIs such as Syphilis, Trichomoniasis, Candidiasis, Chancroid. It also provides HIV counseling. For HIV treatments, HIV patients are transferred to public institutions for ART. We also have some contraceptive methods, but people who need family planning are also transferred to the hospital or health center where the governmental institutions provide these services for free. Moreover, pregnant women in our institution are cared for, for example, on echography, ANC and PNC care, and partial health interventions are provided. The challenge at our facility is a lack of rights to deliver all the SRH services, but we need to create a strong partnership with the Ministry of Health for us to provide them. Said a medical doctor at a private clinic in Kicukiro.
Accessibility of SRH Services to adolescents
The majority of the respondents expressed that their facilities have been providing more information on SRH services (94.3%) and general health (85.7%) after they have provided a specific SRH service to an adolescent. Although more than half of respondents (59.4%) reported that they provided more time for interaction with adolescents, only 46.9% of staff were trained to provide SRH services to adolescents, as shown in table 3.
In-depth interviews showed that interviewees were providing information on where adolescents could access SRH services and their location but not on a routine basis. SRH Services providers felt that all the required information by the adolescents on SRH services are made available during ongoing campaigns organized by different institutions.
“Health providers spread awareness about the available friendly Adolescents’ SRH services when there is a campaign, because adolescents attend it”. Nurse in Huye.
The interviewees also lamented being over-worked by other health care services while providing SRH services. They were scared that the lack of detailed information about their responsibilities at work affected the time spent providing such services to adolescents.
“We don’t have an organogram at our facility because we get assigned any other responsibilities within other units or departments other than the SRH department…………” Nurse in Gasabo.
Table 3 shows that the service providers believe that only (62.8%) of the adolescents travel less than 30- minute walk to reach a venue for accessing SRH services, while the use of social media for education and information provision on SRH were not commonly used (72.2%) by the health facilities. Over half of respondents (51.6%) feel that close to half of the services are provided at a low cost and 49.4% reported that the needs of the adolescents were not being met in their facilities. Furthermore, most of the study respondents responded that they do not provide SRH information to adolescents through social media platforms like Facebook, Whatsapp, and Twitter.
“Social media are not used at the health center because our health center still has the barriers to having required equipment and resources needed for providing the education and information using the social media platforms……………….. ” Midwife in Rubavu.
The respondents believed that it is only at public facilities that adolescents can access SRH services at an average cost. They further said that for those who had access to any medical insurance, access to services is at a price worth searching for them at private facilities.
“The services are provided at low cost because only 15% of the service cost is paid by the client who have health insurance. The patient with no health insurance must pay 100% of the treatments”, Nurse in Nyarugenge added. “Our institution provides various services for private clients, that is why the services we provide, including SRH services for adolescents, are paid 100%, but we accept the health insurance when it is relevant” Nurse in Rwamagana responded.
Quality of SRH Services provided to adolescents
Tables 4, demonstrate the perceived quality of SRH services by services providers provided to adolescents within the urban health facilities in Rwanda. Regarding privacy, 64.3% of health facilities did not separate entrance for adolescents to use while they visit the health facility to access SRH services but 88.5% of respondents expressed that health facilities have private rooms for consultations.
“The providers give SRH services to adolescents in privacy and confidential manners. The socio-demographic and patients’ status are kept in privacy.” Medical Doctor in Musanze.
Table 5 shows that 68.2% of respondents did not present to the interviewer any written guidelines used for SRH services provided to adolescents. Additionally, the respondents felt that only 58.0% had accessed some training on providing SRH services to adolescents, while 73% had continuous access to adolescent SRH education. They added, however, that in-service training and documentation are conducted to provide services to adolescents, whereby they said that they provide SRH services to adolescents without any prejudices and stigmatization and that room for improvement is needed.
A total of 45.9% respondents said that they do not have formal mechanisms to receive feedback from the adolescents on services provided, and only 42.1% of respondents acknowledged to involve adolescents in designing the feedback mechanisms, while only 33.3% of the facilities make use of the adolescents peer educators in SRH services and information provision to adolescents. Respondents expressed respect for privacy and confidentiality while providing SRH services to adolescents. Only half of adolescents have their needs completely satisfied, resulting in half of visits encountering at least one obstacle in accessing the services available.
“The clinic does not have a trained health provider about the SRH services and there is no specific health provider for adolescents seeking SRH services” Nurse in Rubavu. “The staff involve themselves in the continuous learning and online courses”. Nurse in Gasabo. “Although the clients are received without judgment, well welcoming and respectful manners, there is need for more efforts especially in counseling where some fear about coming to seek for the services”. Social worker in Huye.
The respondents said that adolescents do not have a suitable means to provide feedback on the services being provided. This is coupled with the fact that they are less involved in suggesting ideas regarding the services that they would like to have provided to them. These made the respondents feel that the sexual and reproductive health needs of adolescents might not be met in several facilities. “There is no transparent and confidential mechanism for adolescents to submit complaints or feedback about SRH services at the facility, but the adolescents receive results or feedback from the services delivered”. Nurse in Huye.
“The peer’s educator or counselors are not involved in the SRH services offered to adolescents. There is no well-organized system to receive and provide SRH care to adolescents by peers. The SRH department is not active/operative because of the lack of resources. Therefore, the people who were peer educators or peer counselors among adolescents are no longer working. Almost all of the adolescents who were in charge are students. Besides, most of the adolescents in the area surrounding this health center are the students who become available on the weekend and holidays” Nurse in Musanze.
Respondents added that the adolescents' needs are not being met within most of the facilities “The needs of adolescents seeking SRH services are not met at the health center because the services are not specific and there are insufficient resources including equipment materials, medical drugs, tests and insufficient providers” Nurse in Rubavu.
Barriers to SRH services accessibility for adolescents
Table 5 enlists multiple factors that can impact on the accessibility and quality of services. This study also documented the obstacles that the SRH service providers perceive to be limiting seeking to access SRH services for adolescents. Major obstacles that interviewed health providers recognized were religious leaders (65.0%) and family members (68.2%) limiting adolescent’s ability to request or access the SRH services.
The in-depth interview states that the respondents’ efforts to provide adolescents with SRH services are often hindered by either religious members, community members, policies in place, and family members that limit access or seeking behaviors by adolescents.
“The facility faces challenges including the community, family and religious leaders who influence SRH services seeking by adolescents at the facility”. Midwife in Gasabo.
Respondents added that “Cultural influence and religious determinants are major barriers. For example, church leaders do not accept family planning and circumcision. These barriers increase the rate of low accessibility to SRH services at the health center”. Social worker in Rubavu